Outlook: Newsletter of the Society of Behavorial Medicine

Spring 2021

Full Article

Behavioral Medicine, Crisis, and Opportunity in the Time of an Ecodemic

Karl J. Maier, PhD; Population Health Sciences SIG



Crisis can be a point of opportunity. In 2018 I wrote with colleagues in Outlook about behavioral medicine’s “mid-life crisis” around its 40th birthday. Rather than a real crisis, this was a time of opportunity to see the tremendous micro-level advances in precision medicine, not as reductionism redux, but as part of a more complete, ecological biopsychosocial paradigm for our field – a conceptual framework that integrates all levels of analysis and views our natural environment as foundational to addressing the most challenging health problems, from asthma to, yes, zoonotic disease.

But we face a true crisis now with COVID-19, and there is tragedy in the irony that this is likely a zoonotic disease that emerged from the very natural environment that most of medicine has neglected for too long. Yet, the full crisis is not the COVID-19 pandemic alone, but the more insidious and pervasive degradation of our neglected environment - what I’ll call an “ecodemic.” If a pandemic is a disease broadly affecting population health, then an ecodemic is a diseased ecosystem broadly affecting population health.

Zoonotic diseases like COVID-19 are but one manifestation of this ecodemic. Humans are both driving this ecodemic and suffering from it, with little awareness or corrective action, despite two formal “warnings to humanity” by scientists in the past 25 years 1. Decades of consumerism, increasingly westernized diets, and an exploding human population have created increasing demands for energy, industrialized agriculture, and manufacturing practices that drive climate change, biodiversity loss, and the proliferation of zoonotic disease 2,3. Our biosphere – the foundation of our health – is in crisis, and we need to act.


Raising consciousness about the problem may not be the greatest need within behavioral medicine; it seems that we’re already in the preparation stage of change. Climate change was among the most frequently mentioned issues to address in the 2019 “Provocative Questions in Behavioral Medicine” initiative launched by past SBM president Michael Diefenbach. And, visioning work has already begun to support the integration of our collective knowledge in addressing it 4.

For the action stage of our change, we have much to start with if behavioral medicine professionals wish to address environmental issues directly. From creating and teaching a course on psychology and climate change 5, I have found that many theories, research findings, and concepts already used in behavioral medicine readily apply. For example, I regularly engage students in the climate change issue through concepts of perceived risk, perceived norms, response efficacy, stress appraisal, stages of change, and even mindfulness.

Indirectly, many of us are closer to addressing environmental issues than we may realize, with careers addressing health equity, nutrition, physical activity, walkable cities, and obesity, to name a few. These core problem areas are key factors in climate change; The Global Syndemic, for example, is so named for the common socioeconomic factors such as global corporatized food systems and infrastructure that drive the confluence of obesity, undernutrition, and climate change 6. Now with COVID-19, there is increasing realization in medicine for the need and opportunity to address health and environmental issues like these together 7.

Our foundational biopsychosocial model provides a coherent starting point to address this all. I’m excited to convene a symposium on this very topic during our upcoming Annual Meeting, sponsored by the Population Health Sciences SIG, on April 13th: “Climate to COVID, Local to Global: The Biopsychosocial Ecology of Syndemic Prevention and Response.” There we’ll be sharing work on how we can apply the biopsychosocial ecological framework 8 to integrate our efforts across disciplines and specializations to address climate change and intersecting issues like COVID-19 and structural inequities.

Beyond concepts, we as an interdisciplinary field are accustomed to reaching beyond what may be our immediate discipline or core training to expand our basic skillset, such as to learn best practices in communicating our science through dialogue. We can also learn much from those working specifically within sustainability circles. For example, oftentimes stakeholders - from individuals and communities to politicians - are best engaged by framing environmental issues in terms of the legitimate “co-benefits” of action, rather than the environmental issue itself. So, instead of focusing on climate change directly, it can sometimes be productive to focus on the health benefits and cost savings associated with plant-based diets, walking instead of driving, or reducing air pollution.

In behavioral medicine, these co-benefits are typically the primary goal, and highly valued already. Yet, the added value of considering environmental co-benefits in our work may be substantial. In community work, there can be enthusiasm and synergy with participatory research when issues of health, food, equity, and environment are addressed together. Seeing the full implications of our work could also expand our universe of funding opportunities, and expand career directions. Working across disciplines is what we do, and this is increasingly valued, as seen for example in the Growing Convergence Research initiative of the National Science Foundation.

In addition to research, is there a synergy to be found by engaging our patients, too? Consider a recent survey of U.S. adults finding that 72% of Americans think global warming is happening. Over 60% of Americans think the issue is at least somewhat important to them personally, see it as a health issue, are at least somewhat worried about it, and feel a personal sense of responsibility to help reduce it. These numbers suggest a likelihood that many of our patients have environmental awareness and concerns that might complement their health behavior goals. For example, moving toward a plant-based diet can have significant health benefits for clients, and it is one of the most necessary societal shifts to address environmental problems like climate change 9. Other clients living in urban food deserts could be empowered by helping establish green spaces for activity and growing fresh food.

Because every client and community is different, we do best when we meet each where they’re at. Not all clients will, or need to, respond to environmental motivations. Not all research and policy should, or can, directly address environmental concerns. But we have the opportunity to be agents of positive environmental change where we can in order to safeguard what is perhaps the ultimate foundation of our health. Evidence tells us that self-motivated, gradual change in attitudes and behavior tend to be the most sustainable over time, and our current ecodemic crisis tells us we should also work toward changes that are sustainable for our environment.



  1. Ripple, W. J. et al. World Scientists’ Warning to Humanity: A Second Notice. BioScience 67, 1026–1028 (2017).
  2. Tilman, D. & Clark, M. Global diets link environmental sustainability and human health. Nature 515, 518–522 (2014).
  3. Tollefson, J. Why deforestation and extinctions make pandemics more likely. Nature 584, 175–176 (2020).
  4. Diefenbach, M. A., Phillips, A. & Bullock, L. Provocative Questions in Behavioral Medicine and the Acceleration of our Science. Annals of Behavioral Medicine 54, 920–923 (2020).
  5. Maier, K. J., Whitehead, G. I. & Walter, M. I. Teaching Psychology and Climate Change: One Way to Meet the Call for Action. Teaching of Psychology 45, 226–234 (2018).
  6. Swinburn, B. A. et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. The Lancet 393, 791–846 (2019).
  7. Watts, N. et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. The Lancet (2020) doi:10.1016/S0140-6736(20)32290-X.
  8. Maier, K. J. & al’Absi, M. Toward a Biopsychosocial Ecology of the Human Microbiome, Brain-Gut Axis, and Health. Psychosomatic Medicine 79, 947–957 (2017).
  9. Willett, W. et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet 393, 447–492 (2019).

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